Robotic surgeries costlier but safer: study

NEW YORK (Reuters Health) - Patients who undergo robot-assisted surgeries on the kidneys or prostate have shorter hospital stays, a lower risk of getting a blood transfusion or dying, and a significantly higher bill compared to those who get older surgical procedures, a new study finds.

The analysis compared robotic surgery with two other techniques for performing the same sorts of surgery, and found that direct costs can run up to several thousand dollars higher for the robotic version. But the study wasn't able to gauge less obvious measures of effectiveness, like whether patients' quality of life over the long run is harmed or improved by one type of surgery or another.

"The value of this study is it documents there are some advantages" to robotic surgery, said Dr. David Penson, a surgeon at Vanderbilt University Medical Center, who was not involved in the work.

"But we should have done this years ago," he said. "I think there was excitement in the general population and there was a lot of marketing about robotic surgery ahead of any proven benefit to the procedure," Penson told Reuters Health.

Robotic surgical equipment is becoming increasingly common in U.S. operating rooms, and seemingly popular with both patients and doctors. The technology replaces a surgeon's hands with ultra-precise tools at the ends of mechanical arms -- all operated by the surgeon from a console.

Touted as less invasive and more efficient, robotic surgeries typically use a laparoscopic, or "keyhole surgery," approach, in which tools and a tiny video camera are inserted into the patient's body through one or two small incisions.

Even standard laparoscopic surgery, in which the doctor works through incisions with hand-held tools, is known to reduce the length of patient hospital stays and recuperation time, compared to open surgeries.

That robotic surgeries are costlier is also well known. Not only is the equipment expensive -- ranging up to one million dollars for a full system -- but surgeons have to invest time in learning how to use it.

To see if that extra cost comes with any benefits over either standard laparoscopic or open surgeries, Dr. Jim Hu at Brigham and Women's Hospital in Boston and his colleagues analyzed surgery data from a national government database.

"It's timely because of spiraling healthcare costs, and one needs to look more closely at comparative effectiveness to justify the cost of these procedures," Hu told Reuters Health.

Hu's team decided to focus on urologic surgeries because that's the field that has adopted robotic surgery most rapidly, he said.

During the last three months of 2008 -- the most recent data available that allowed a comparison among the three approaches -- more than half of all prostate removals involved a robot-assisted surgery, the team found.

About three percent of patients underwent standard laparoscopic surgery and 44 percent underwent open surgery.

Open and laparoscopic surgeries were still more common than robotic surgeries for kidney repairs and removals.

Among the men who had their prostate removed, none died from laparoscopic or robotic surgery, whereas two out of every thousand died after the open procedure.

Also, about five percent of the men who had open surgery needed a blood transfusion, compared to less than two percent of the men who had robot-assisted surgery. The open-surgery group also stayed in the hospital about one day longer than the robotic group.

The outcomes were similar for people who had their kidneys removed.

"I think the take home message is that robotic, looking at our study, had certain beneficial outcomes compared to open and laparoscopic procedures," said Hu.

The trade-off for those benefits can be found in the bill.

On average, robotic surgery to remove the prostate cost about $10,000 -- roughly $700 more than laparoscopic surgery and $1,100 more than open surgery.

For a kidney removal, robotic surgery cost $13,900, which was $2,700 more than laparoscopic and $1,300 more than open surgery.

Penson, who wrote an editorial accompanying the paper in The Journal of Urology, said the benefits of robotic surgery are smaller than had been expected.

"Years ago, this was thought to be the be-all-end-all operation, particularly with prostate surgery. We were going to get patients out of the hospital quicker, have better potency and incontinence outcomes," said Penson.

"And the reality of it is that we climbed the mountain, relearned to do this operation, and there are some benefits, but not as much as we had hoped," he added.

Penson said the study was well done, but lacked some valuable measures, such as how well people fared after the surgeries in terms of their ability to have an erection or remain continent, for instance.

Hu cautioned against putting too much faith in procedure alone. The talent of a surgeon can make a big difference to a surgery's success.

"I would emphasize that it's important to look beyond open versus robotic. Patients have to keep in mind the experience and skill of the surgeon as important," Hu said.

He recommends that patients interview surgeons and ask for recommendations before making a decision about which procedure to choose.

Penson said that because of the added costs of robotic surgery, studies like this should be done as soon as the technology becomes available, rather than a decade later.

"Ultimately, we have to generate comparative effectiveness (studies), because ultimately patients will have to pay more for their healthcare," Penson said. "And they will want to know if it's worth it."